Access Barriers Form
The purpose of this form is to collect information about the access barriers our clients are facing to guide our advocacy efforts and provide direct follow up to clients.
Your Information
First Name:
Last Name:
Email:
Incident Detail
Date of Incident
Type of setting or service involved:
Please select...
Airport/Airline
TSA
Hotel/Alternative Lodging
Housing
Restaurant
Business
Public Transportation
Rideshare
Workplace
Other (detail below)
Other (detail below)
Location of incident (city/state or approximate area)
Please describe what happened:
Who was involved if known:
Please select...
Driver
Manager
Security
Staff
Other (detail below)
Other (detail below)
Have you reported this incident?:
Please select...
Yes
No
If yes, please indicate where (e.g. DOJ, State agency, Business/Organization, other)
Would you like us to contact you for follow-up or additional information?:
Please select...
Yes
No
Contact Information